Wednesday, November 27, 2013

Q: Out of following
which one may be use as an adjuvant treatment in Thyrotoxic Periodic Paralysis
(TTP)?

A) Calcium Channel
Blockers

B) Non selective Beta Blockers
(propranolol)

C)
Corticosteroids

D) Intravenous
magnesium

E) Intravenous
Dextrose

Answer: B (Non
selective Beta Blockers -propranolol)

In Thyrotoxic Periodic Paralysis (TTP),
propranolol, a nonselective beta-blocker, has shown to prevent the intracellular
shift of potassium and phosphate by blunting the hyperadrenergic stimulation of
Na+/ K+–ATPase. Studies have shown tha propranolol given alone (orally or iv)
normalizes serum potassium levels on an average of 2 hours. It is recommended to
use with main treatment if blood pressure can
tolerate.

Tuesday, November 26, 2013

A 19-year-old man presented to the Emergency
Department in a comatose state with seizure-like activity 2 hours after
ingesting a quart of soy sauce. He was administered 6 L of free water over 30
min and survived neurologically intact without clinical sequelae. Corrected for
hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is
the highest documented level in an adult patient to survive an acute sodium
ingestion without neurologic deficits.

Monday, November 25, 2013

Answer:Warfarinization (start of warfarin) initially and temporarily may promote clot formation. This is due to the fact that the level of protein C and protein S are also dependent on vitamin K activity. Warfarin causes drop in protein C levels in first 36 hours. Also, reduced levels of protein S lead to a reduction in activity of protein C, for which it is the co-factor. This leads to a prothrombotic state. Thus, when warfarin is loaded at greater than 5 mg per day, it is advisable to co-administer heparin.

Sunday, November 24, 2013

Q: What is the optimum time of administrating Nimodipine in Subarachnoid Hemorrhage (SAH)?

Answer: In subarachnoid hemorrhage (SAH), nimodipine's is use primarily in the prevention of cerebral vasospasm. It should be started within 4 days of a subarachnoid hemorrhage (SAH) and should be continued for 21 days. Nimodipine is a calcium channel blocker and has selectivity for cerebral vasculature.

Saturday, November 23, 2013

Q: What are the best places to
obtain TCD (Trans Cranial Doppler)?

Answer:The
bones of the skull block the transmission of ultrasound, so areas with thinner
walls, called insonation windows get used for procedure. For Most preffered
areas are the temporal region above the cheekbone/zygomatic arch, through the
eyes, below the jaw, and from the back of the head.

Thursday, November 21, 2013

The risk of catheter-related bloodstream infection
with femoral venous catheters as compared to subclavian and internal jugular
venous catheters: a systematic review of the literature and
meta-analysis.

BACKGROUND:

Catheter-related bloodstream infections are an important cause
of morbidity and mortality in hospitalized patients. Current guidelines
recommend that femoral venous access should be avoided to reduce this
complication (1A recommendation). However, the risk of catheter-related
bloodstream infections from femoral as compared to subclavian and internal
jugular venous catheterization has not been systematically reviewed.

OBJECTIVE:

A systematic review of the literature to determine the risk of
catheter-related bloodstream infections related to nontunneled central venous
catheters inserted at the femoral site as compared to subclavian and internal
jugular placement.

STUDY SELECTION:

Randomized controlled trials and cohort studies that reported
the frequency of catheter-related bloodstream infections (infections per 1,000
catheter days) in patients with nontunneled central venous catheters placed in
the femoral site as compared to subclavian or internal jugular placement.

DATA SYNTHESIS:

Two randomized controlled trials (1006 catheters) and 8 cohort
(16,370 catheters) studies met the inclusion criteria for this systematic
review. Three thousand two hundred thirty catheters were placed in the
subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein
for a total of 113,652 catheter days. The average catheter-related bloodstream
infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the
risk of catheter-related bloodstream infections between the femoral and
subclavian/internal jugular sites in the two randomized controlled trials
(i.e., no level 1A evidence). There was no significant difference in the risk of
catheter-related bloodstream infections between the femoral and subclavian
sites. The internal jugular site was associated with a significantly lower risk
of catheter-related bloodstream infections compared to the femoral site (risk
ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference
was explained by two of the studies that were statistical outliers. When these
two studies were removed from the analysis there was no significant difference
in the risk of catheter-related bloodstream infections between the femoral and
internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19,
p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the
risk of infection and the year of publication (p=.01), with the femoral site
demonstrating a higher risk of infection in the earlier studies. There was no
significant difference in the risk of catheter-related bloodstream infection
between the subclavian and internal jugular sites. The risk of deep venous
thrombosis was assessed in the two randomized controlled trials. A meta-analysis
of this data demonstrates that there was no difference in the risk of deep
venous thrombosis when the femoral site was compared to the subclavian and
internal jugular sites combined. There was, however, significant heterogeneity
between studies.

CONCLUSIONS:

Although earlier studies showed a lower risk of catheter-related
bloodstream infections when the internal jugular was compared to the femoral
site, recent studies show no difference
in the rate of catheter-related bloodstream infections between the three
sites.

Wednesday, November 6, 2013

Non-rebreather masks are designed to capture the first 150ml of the exhaled breath into the reservoir bag for inhalation during the subsequent breath. Clinical significance: This portion of the breath was initially delivered at the end of inhalation and was therefore delivered to the "deadspace" anatomy where gas exchange does not occur. Therefore, there would be no depletion of oxygen nor gain of carbon dioxide during the rebreathing component.

Background

Patients
who receive heart transplants may undergo therapeutic plasma exchange to reduce
high levels of HLA antibodies which may increase the risk of allograft
rejection. Plasma exchange may predispose to hypocalcemia because of chelation
of calcium by sodium citrate, used as an anticoagulant both during the procedure
and in thawed fresh frozen plasma often used for replacement.

Methods

We
report three adults with dilated cardiomyopathy who underwent cardiac
transplantation and serial plasma exchange for high levels of HLA antibodies. We
followed these patients’ pre-exchange serum calcium levels and the quantity of
calcium supplementation they received. Further, we examined myocardial tissue
sections post-transplantation for calcium deposition.

Results

Our
patients’ serum calcium levels were initially normal, but, despite aggressive
calcium repletion, remained low (nadirs for pre-exchange ionized calcium in two
patients 4.48 and 3.8 mg/dL, respectively, reference range 4.6–5.4 mg/dL). For
patient 3, pre-exchange total calcium on day 2 was 7.9 mg/dL (reference range
8.4–10.2 mg/dL). Two patients had intermittent symptoms of hypocalcemia. Studies
of cardiac tissue sections (available only from these two patients) were
consistent with the presence of calcium deposition post transplantation. In comparison, six patients who underwent lung
transplantation and plasma exchange for high levels of HLA antibodies did not
manifest significant hypocalcemia.

Conclusions

We
emphasize the need for prompt and sufficient calcium replacement, monitored by
serum ionized calcium levels, in the early post-cardiac transplantation period
when plasma exchange is performed with thawed fresh frozen plasma replacement.
The persistently low serum calcium
levels we observed post heart transplantation were possibly contributed to by
increased myocardial calcium influx.

Sunday, November 3, 2013

Q:What is Todd's Paresis?

Answer:Todd's paresis is focal paralysis which occurs after seizure, and
usually resolves within a day or two. Usually, it presents as hemiplegia.
Todd's paresis may also
presents difficulty in speech, gaze
problems or blurred vision. It affects around 10%
of seizures.

The most challenging part is to
determine whether seizure is the cause of motor weakness or is the result of
CVA. Fortunately, in most cases it resolves quickly.

Saturday, November 2, 2013

Q:What is the pathophysiology of playtpnea in Hepatopulmonary
syndrome?Answer:In hepatopulmonary syndrome, there is a shunting and V/Q mismatch due to
arteriovenous malformations in the lung. Platypnea and orthodeoxia occur because
the pulmonary AVMs occur predominantly in the bases of the lung. Therefore, when
sitting up or standing, blood pools at the bases of the lung with resultant
increased AV shunting.